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Alves D, Pereira MO, Lopes SP. Co-immobilization of Ciprofloxacin and Chlorhexidine as a Broad-Spectrum Antimicrobial Dual-Drug Coating for Poly(vinyl chloride) (PVC)-Based Endotracheal Tubes. ACS APPLIED MATERIALS & INTERFACES 2024; 16:16861-16879. [PMID: 38507790 PMCID: PMC10995906 DOI: 10.1021/acsami.4c01334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/23/2024] [Accepted: 03/05/2024] [Indexed: 03/22/2024]
Abstract
The endotracheal tube (ETT) affords support for intubated patients, but the increasing incidence of ventilator-associated pneumonia (VAP) is jeopardizing its application. ETT surfaces promote (poly)microbial colonization and biofilm formation, with a heavy burden for VAP. Devising safe, broad-spectrum antimicrobial materials to tackle the ETT bioburden is needful. Herein, we immobilized ciprofloxacin (CIP) and/or chlorhexidine (CHX), through polydopamine (pDA)-based functionalization, onto poly(vinyl chloride) (PVC) surfaces. These surfaces were characterized regarding physicochemical properties and challenged with single and polymicrobial cultures of VAP-relevant bacteria (Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, Staphylococcus aureus, Staphylococcus epidermidis) and fungi (Candida albicans). The coatings imparted PVC surfaces with a homogeneous morphology, varied wettability, and low roughness. The antimicrobial immobilization via pDA chemistry was still evidenced by infrared spectroscopy. Coated surfaces exhibited sustained CIP/CHX release, retaining prolonged (10 days) activity. CIP/CHX-coated surfaces evidencing no A549 lung cell toxicity displayed better antibiofilm outcomes than CIP or CHX coatings, preventing bacterial attachment by 4.1-7.2 Log10 CFU/mL and modestly distressingC. albicans. Their antibiofilm effectiveness was endured toward polymicrobial consortia, substantially inhibiting the adhesion of the bacterial populations (up to 8 Log10 CFU/mL) within the consortia in dual- and even inP. aeruginosa/S. aureus/C. albicans triple-species biofilms while affecting fungal adhesion by 2.7 Log10 CFU/mL (dual consortia) and 1 Log10 CFU/mL (triple consortia). The potential of the dual-drug coating strategy in preventing triple-species adhesion and impairing bacterial viability was still strengthened by live/dead microscopy. The pDA-assisted CIP/CHX co-immobilization holds a safe and robust broad-spectrum antimicrobial coating strategy for PVC-ETTs, with the promise laying in reducing VAP incidence.
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Affiliation(s)
- Diana
Filipa Alves
- CEB
- Centre of Biological Engineering, University
of Minho, 4710-057 Braga, Portugal
- LABBELS—Associate
Laboratory, 4710-057 Braga/Guimarães, Portugal
| | - Maria Olívia Pereira
- CEB
- Centre of Biological Engineering, University
of Minho, 4710-057 Braga, Portugal
- LABBELS—Associate
Laboratory, 4710-057 Braga/Guimarães, Portugal
| | - Susana Patrícia Lopes
- CEB
- Centre of Biological Engineering, University
of Minho, 4710-057 Braga, Portugal
- LABBELS—Associate
Laboratory, 4710-057 Braga/Guimarães, Portugal
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Bustos IG, Martín-Loeches I, Acosta-González A, Chotirmall SH, Dickson RP, Reyes LF. Exploring the complex relationship between the lung microbiome and ventilator-associated pneumonia. Expert Rev Respir Med 2023; 17:889-901. [PMID: 37872770 DOI: 10.1080/17476348.2023.2273424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/17/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Understanding the presence and function of a diverse lung microbiome in acute lung infections, particularly ventilator-associated pneumonia (VAP), is still limited, evidencing significant gaps in our knowledge. AREAS COVERED In this comprehensive narrative review, we aim to elucidate the contribution of the respiratory microbiome in the development of VAP by examining the current knowledge on the interactions among microorganisms. By exploring these intricate connections, we endeavor to enhance our understanding of the disease's pathophysiology and pave the way for novel ideas and interventions in studying the respiratory tract microbiome. EXPERT OPINION The conventional perception of lungs as sterile is deprecated since it is currently recognized the existence of a diverse microbial community within them. However, despite extensive research on the role of the respiratory microbiome in healthy lungs, respiratory chronic diseases and acute lung infections such as pneumonia are not fully understood. It is crucial to investigate further the relationship between the pathophysiology of VAP and the pulmonary microbiome, elucidating the mechanisms underlying the interactions between the microbiome, host immune response and mechanical ventilation for the development of VAP.
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Affiliation(s)
- Ingrid G Bustos
- Unisabana Center for Translational Science, School of Medicine, Universidad de La Sabana, Chia, Colombia
- Doctorado de Biociencias, Department of Engineering, Universidad de la Sabana, Chia, Colombia
| | - Ignacio Martín-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Dublin, Ireland
| | - Alejandro Acosta-González
- Unisabana Center for Translational Science, School of Medicine, Universidad de La Sabana, Chia, Colombia
- Bioprospection Research Group (GIBP), Department of Engineering, Universidad de La Sabana, Chia, Colombia
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Robert P Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
- Weil Institute for Critical Care Research & Innovation, Ann Arbor, MI, USA
| | - Luis Felipe Reyes
- Unisabana Center for Translational Science, School of Medicine, Universidad de La Sabana, Chia, Colombia
- Critical Care Department, Clinica Universidad de La Sabana, Chia, Colombia
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
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Han Y, Zuo Y, Luo Z, Ju M, Hua J, He B, Wu Y, Zhang J. Positive sputum culture of Candida spp . as a risk factor for 30-day mortality in patients with hospital-acquired pneumonia: A propensity-score matched retrospective clinical study. CHINESE MEDICAL JOURNAL PULMONARY AND CRITICAL CARE MEDICINE 2023; 1:113-118. [PMID: 39170823 PMCID: PMC11332850 DOI: 10.1016/j.pccm.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Indexed: 08/23/2024]
Abstract
Background Candida species (Candida spp.) are commonly isolated microorganisms from lower respiratory tract (LRT) specimens of patients with hospital-acquired pneumonia (HAP); however, the clinical significance remains controversial. This study aimed to investigate the correlation between Candida spp. in the LRT and the clinical features and prognosis of HAP. Methods This retrospective analysis included eligible patients with HAP from the database of a prospective study carried out between 2018 and 2019 in nine Chinese hospitals. Data on demographics, clinical characteristics, and prognosis were collected and analyzed. Propensity score matching (PSM) was used to balance the baseline characteristics. Results A total of 187 HAP patients were enrolled. After PSM of severity score, 27 cases with positive sputum culture of Candida spp. were compared with the control group at a ratio of 1:1. The Candida-positive group had more bacterial isolates in blood culture than the Candida-negative group (39.1% [9/23] vs. 7.7% [2/26],χ 2 = 6.928, effect size [ES] = 0.38, 95% CI: 0.12-0.61, P = 0.008). The proportion of patients with chronic lung diseases was significantly higher in the Candida-positive group (55.6% [15/27] vs. 22.2% [6/27],χ 2 = 6.312, ES = 0.34, 95% CI: 0.07-0.59, P = 0.012). The 30-day prognosis of HAP was significantly different between the two groups (80.8% [21/26] vs. 38.5% [10/26],χ 2 = 9.665, ES = 0.43, 95% CI: 0.19-0.66, P = 0.002). Univariable logistic regression analysis showed that LRT Candida spp. colonization was a risk factor for 30-day mortality of HAP (OR = 6.720, 95% CI: 1.915-23.577, P = 0.003). Conclusions Candida spp. in the LRT was associated with 30-day mortality of HAP. Patients with chronic underlying lung diseases tend to have Candida spp. colonization.
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Affiliation(s)
- Yaopin Han
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yihui Zuo
- Department of Clinical Medicine, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Minjie Ju
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jianlan Hua
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Binfeng He
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yixing Wu
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jing Zhang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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Britton N, Yang H, Fitch A, Li K, Seyed K, Guo R, Qin S, Zhang Y, Bain W, Shah F, Biswas P, Choi W, Finkelman M, Zhang Y, Haggerty CL, Benos PV, Brooks MM, McVerry BJ, Methe B, Kitsios GD, Morris A. Respiratory Fungal Communities are Associated with Systemic Inflammation and Predict Survival in Patients with Acute Respiratory Failure. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.11.23289861. [PMID: 37292915 PMCID: PMC10246035 DOI: 10.1101/2023.05.11.23289861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Rationale Disruption of respiratory bacterial communities predicts poor clinical outcomes in critical illness; however, the role of respiratory fungal communities (mycobiome) is poorly understood. Objectives We investigated whether mycobiota variation in the respiratory tract is associated with host-response and clinical outcomes in critically ill patients. Methods To characterize the upper and lower respiratory tract mycobiota, we performed rRNA gene sequencing (internal transcribed spacer) of oral swabs and endotracheal aspirates (ETA) from 316 mechanically-ventilated patients. We examined associations of mycobiome profiles (diversity and composition) with clinical variables, host-response biomarkers, and outcomes. Measurements and Main Results ETA samples with >50% relative abundance for C. albicans (51%) were associated with elevated plasma IL-8 and pentraxin-3 (p=0.05), longer time-to-liberation from mechanical ventilation (p=0.04) and worse 30-day survival (adjusted hazards ratio (adjHR): 1.96 [1.04-3.81], p=0.05). Using unsupervised clustering, we derived two clusters in ETA samples, with Cluster 2 (39%) showing lower alpha diversity (p<0.001) and higher abundance of C. albicans (p<0.001). Cluster 2 was significantly associated with the prognostically adverse hyperinflammatory subphenotype (odds ratio 2.07 [1.03-4.18], p=0.04) and predicted worse survival (adjHR: 1.81 [1.03-3.19], p=0.03). C. albicans abundance in oral swabs was also associated with the hyperinflammatory subphenotype and mortality. Conclusions Variation in respiratory mycobiota was significantly associated with systemic inflammation and clinical outcomes. C. albicans abundance emerged as a negative predictor in both the upper and lower respiratory tract. The lung mycobiome may play an important role in the biological and clinical heterogeneity among critically ill patients and represent a potential therapeutic target for lung injury in critical illness.
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Affiliation(s)
- Noel Britton
- Division of Pulmonary Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Haopu Yang
- School of Medicine, Tsinghua University, Beijing, China
| | - Adam Fitch
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Center for Medicine and the Microbiome, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kelvin Li
- Center for Medicine and the Microbiome, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Khaled Seyed
- Department of Epidemiology, University of Florida, Gainesville, Florida, USA
| | - Rui Guo
- Department of Critical Care Medicine, First Affiliated Hospital of Chongqing Medical University, China
| | - Shulin Qin
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Center for Medicine and the Microbiome, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yingze Zhang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - William Bain
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Faraaz Shah
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Partha Biswas
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Wonseok Choi
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Yonglong Zhang
- Associates of Cape Cod Inc., East Falmouth, Massachusetts, USA
| | - Catherine L. Haggerty
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Panayiotis V. Benos
- Department of Epidemiology, University of Florida, Gainesville, Florida, USA
| | - Maria M. Brooks
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Bryan J. McVerry
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Center for Medicine and the Microbiome, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Barbara Methe
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Center for Medicine and the Microbiome, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Georgios D. Kitsios
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Center for Medicine and the Microbiome, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alison Morris
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Center for Medicine and the Microbiome, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Ioannou P, Vouidaski A, Spernovasilis N, Alexopoulou C, Papazachariou A, Paraschou E, Achyropoulou A, Maraki S, Samonis G, Kofteridis DP. Candida spp. isolation from critically ill patients' respiratory tract. Does antifungal treatment affect survival? Germs 2021; 11:536-543. [PMID: 35096670 DOI: 10.18683/germs.2021.1288] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 10/30/2021] [Accepted: 11/02/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Isolation of Candida spp. from bronchial samples of patients on mechanical ventilation is common. Even though it may not always reflect infection, it may induce immunological changes that can facilitate bacterial pneumonia. In this case, antifungal treatment is of uncertain value. This study examined the impact of antifungal treatment on the outcome of intensive care unit (ICU)-acquired respiratory tract infection (RTI) of critically ill, immunocompetent patients, with Candida isolation from their respiratory tract. METHODS This is a retrospective cohort study of adult patients hospitalized in the ICU of the University Hospital of Heraklion, Greece, from 2014 through 2016 with ICU-acquired RTI and Candida spp. isolated from their bronchial secretions. Data regarding medical history, demographics (gender, age), reason for ICU admission, previous antimicrobial use or hospitalization, SOFA and APACHE II score, clinical outcomes (primary clinical outcome: overall mortality during hospitalization; secondary clinical outcome: mortality during the ICU stay and duration of ICU and hospital stay) at the end of their ICU stay and at the end of their hospital stay were recorded and consequently evaluated. A logistic regression analysis model evaluated the effect of the recorded parameters in association with ICU mortality and overall mortality during hospitalization. RESULTS A total of 90 individuals were enrolled. Of them, 47 (52.2%) were treated with antifungals during their hospitalization around the time of Candida isolation. Patients treated with antifungals had higher SOFA and APACHE II scores, longer duration of stay in the ICU, more days on ventilator and higher total mortality during hospitalization. Multivariate logistic regression analysis identified antifungal use to be independently associated with total mortality during hospitalization. CONCLUSIONS Antifungal use in patients with ICU-acquired RTI was associated with higher overall mortality as compared to those not receiving such agents.
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Affiliation(s)
- Petros Ioannou
- MD, MSc, PhD Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Stavrakia and Voutes crossroad, Heraklion, PC 71110, Crete, Greece
| | - Alexandra Vouidaski
- MD, Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, PC 71110, Crete, Greece
| | - Nikolaos Spernovasilis
- MD, MSc Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, PC 71110, Crete, Greece
| | - Christina Alexopoulou
- MD, PhD, Intensive Care Unit, University Hospital of Heraklion, Heraklion, PC 71110, Crete, Greece
| | - Andria Papazachariou
- MD, Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, PC 71110, Crete, Greece
| | - Eleni Paraschou
- MD, Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, PC 71110, Crete, Greece
| | - Aikaterini Achyropoulou
- MD, Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, PC 71110, Crete, Greece
| | - Sofia Maraki
- MD, PhD, Department of Microbiology, University Hospital of Heraklion, Heraklion, PC 71110 Crete, Greece
| | - George Samonis
- MD, PhD, Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, PC 71110, Crete, Greece
| | - Diamantis P Kofteridis
- MD, PhD, Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, PC 71110, Crete, Greece
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Candida Spp. in Lower Respiratory Tract Secretions - A Ten Years Retrospective Study. J Crit Care Med (Targu Mures) 2021; 7:217-226. [PMID: 34722925 PMCID: PMC8519383 DOI: 10.2478/jccm-2021-0016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/24/2021] [Indexed: 12/27/2022] Open
Abstract
Introduction Lower respiratory tract secretions (LRTS) like sputum and tracheal aspirates are frequently sent to the microbiology laboratory from patients with various respiratory pathologies. Improper collection techniques can lead to false-positive results, resulting in improper therapy. Aim of the study To determine the percentage of contaminated samples sent to the microbiology laboratory, to establish the prevalence of Candida spp. in non-contaminated samples and therefore, the presence of Candida spp. originating in lower respiratory tract infections. Material and Methods A 10-year data survey was conducted to assess the differences in Candida prevalence from contaminated versus non-contaminated samples, assessed and categorised by Bartlett grading system, and to emphasise the importance of quality control for potentially contaminated samples. The data were analysed according to gender, age, referring departments, and the species of Candida. For the statistical analysis, Kruskal-Wallis and Fisher tests were used, and the alpha value was set for 0.5. Results The prevalence of Candida spp. in all analysed samples was 31.60%. After excluding the contaminated samples, the actual prevalence was 27.66%. Of all sputum samples, 31.6% were contaminated. Patients aged more than 40 years old were more prone to provide contaminated sputum samples. C. albicans is more prevalent in non-contaminated sputum samples. In both sputum and tracheal aspirates, the chances of identifying a single species are higher than the chances of identifying multiple species. Conclusions The study emphasises the importance of assessing the quality of sputum samples because of the high number of improperly collected samples sent to the microbiology laboratory.
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Zuo YH, Wang WQ, Chen QJ, Liu B, Zhang FY, Jin XY, Hang JQ, Li HY, Bao ZY, Jie ZJ, Wang GF, Gao XW, Sun H, Xu JF, Zhang J, Qu JM. Candida in Lower Respiratory Tract Increases the Frequency of Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Retrospective Case-Control Study. Front Cell Infect Microbiol 2020; 10:538005. [PMID: 33117725 PMCID: PMC7561360 DOI: 10.3389/fcimb.2020.538005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/02/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: To explore impact of Candida on the acute exacerbation of chronic obstructive pulmonary disease (AECOPD) outcome. Methods: A retrospective, multi-center, case-control study was performed. Patients hospitalized for AECOPD in 25 centers during Jan 2011-Dec 2016 were enrolled. Data were collected, including demographic information, conditions during the stable phase of COPD, clinical characteristics of AECOPD, and follow-up information within 1 year after discharge. Univariate analysis and binary logistic regression were applied, and p < 0.05 was regarded as significant. Results: Totally 1,103 patients were analyzed, with 644 lower respiratory airway (LTR) Candida positive cases and 459 Candida negative controls. Long-term prognosis was significantly different between Candida positive and negative group, including the recurrent AECOPD within 180 days (75.5 vs. 6.6%, p < 0.001) and mortality within 1 year (6.9 vs. 0.4%, p < 0.001). Univariate logistic analysis showed that LTR Candida isolation was related to higher recurrence rate of AECOPD within 180 days and mortality within 1 year. Binary logistic regression analysis demonstrated that LTR Candida isolation was independently associated with recurrence of AECOPD within 180 days. Conclusions: LTR Candida isolation was associated with worse long-term prognosis of AECOPD and independently related to higher risks of recurrent AECOPD within 180 days.
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Affiliation(s)
- Yi-hui Zuo
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei-qin Wang
- Department of Respiratory Medicine, Tongren Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Department of Respiratory Medicine, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qi-jian Chen
- Department of Respiratory Medicine, School of Medicine, Ruijin North Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Bin Liu
- Department of Respiratory Medicine, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Feng-ying Zhang
- Department of Respiratory Medicine, Shanghai Putuo District People's Hospital, Shanghai, China
| | - Xiao-yan Jin
- Department of Respiratory Medicine, Tongren Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jing-qing Hang
- Department of Respiratory Medicine, Shanghai Putuo District People's Hospital, Shanghai, China
| | - Hua-yin Li
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhi-yao Bao
- Department of Respiratory Medicine, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhi-jun Jie
- Department of Respiratory Medicine, Shanghai Fifth' Peoples Hospital, Fudan University, Shanghai, China
| | - Gui-fang Wang
- Department of Respiratory Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Xi-wen Gao
- Department of Respiratory Medicine, Central Hospital of Minhang District, Shanghai, Fudan University, Shanghai, China
| | - He Sun
- Department of Respiratory Medicine, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jin-fu Xu
- Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
| | - Jing Zhang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jie-ming Qu
- Department of Respiratory Medicine, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
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Huang D, Qi M, Hu Y, Yu M, Liang Z. The impact of Candida spp airway colonization on clinical outcomes in patients with ventilator-associated pneumonia: A systematic review and meta-analysis. Am J Infect Control 2020; 48:695-701. [PMID: 31813630 DOI: 10.1016/j.ajic.2019.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/04/2019] [Accepted: 11/04/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous studies have drawn different conclusions about the impact of Candida airway colonization on clinical outcomes in patients with ventilator-associated pneumonia (VAP). METHODS We searched PubMed, the Cochrane Library, Embase (via OVID), and Web of Science database. We included both retrospective and prospective observational studies. The mean difference (MD) or risk ratio (RR) with 95% confidence intervals (CI) were applied to assess the association between Candida colonization and clinical outcomes. RESULTS A total of 8 studies with 1,661 patients were pooled in our final studies. Compared with patients with VAP without Candida colonization, patients with Candida colonization had significantly longer durations of mechanical ventilation (MD, 1.93; 95% CI, 0.53-3.33). The intensive care unit (ICU) length of stay seems to be longer among Candida colonized patients than noncolonized patients, although the results were not so significant (MD, 1.15; 95% CI, -1.04 to 3.34). Patients with colonization had higher 28-day mortality and ICU mortality than those without colonization (28-day mortality: RR, 1.64; 95% CI, 1.27-2.12; ICU mortality: RR, 1.57; 95% CI, 1.26-1.94). CONCLUSIONS The presence of Candida spp airway colonization is associated with longer durations of mechanical ventilation, higher 28-day mortality, higher ICU mortality, and probably longer ICU length of stay compared with the absence of colonization in patients with VAP.
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Cortegiani A, Einav S. Being candid about Candida airway colonization and clinical outcomes: What can we really learn from unadjusted associations? Am J Infect Control 2020; 48:587-588. [PMID: 32173124 DOI: 10.1016/j.ajic.2020.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 01/31/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Andrea Cortegiani
- Section of Anesthesia, Analgesia, Intensive Care and Emergency, Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy.
| | - Sharon Einav
- Intensive Care Unit, Shaare Zedek Medical Medical Centre, Jerusalem, Israel; Hebrew University Faculty of Medicine, Jerusalem, Israel
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Impact of bronchial colonization with Candida spp. on the risk of bacterial ventilator-associated pneumonia in the ICU: the FUNGIBACT prospective cohort study. Intensive Care Med 2019; 45:834-843. [PMID: 31020361 DOI: 10.1007/s00134-019-05622-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/13/2019] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Respiratory tract Candida spp. colonization is associated with more frequent bacterial ventilator-associated pneumonia (VAP). However, this colonization could be causally related to VAP or simply reflect the immune paralysis associated with multiple organ failure. OBJECTIVE To prospectively evaluate the relationship between Candida spp. colonization and bacterial VAP in mechanically ventilated patients with multiple organ failure. INCLUSION Patients receiving mechanical ventilation for > 4 days and presenting multiple organ failure were included. Tracheal colonization with Candida spp. was evaluated at inclusion (day 0, D0) and every 4 days until extubation. Quantitative proximal and tracheal cultures were performed at each VAP episode. Monocyte human leukocyte antigen-DR isotype (mHLA-DR) expression and the ratio of polymononuclear leukocytes to lymphocytes were used to evaluate immunoparalysis at D0 and D7. The relationship between fungal colonization and VAP was modelled using cause-specific models for repeated events with adjustment for time-dependent confounders and immune factors. RESULTS A total of 213 patients, with a median age of 64, simplified acute physiology score II (SAPS II) score 55 and sequential organ failure assessment (SOFA) score 10, mainly admitted for medical reasons (n = 197, 92%), were enrolled in 2012-2015. The median ICU stay was 24 days and the mortality rate was 32% (69 cases). Median mHLA-DR was 5916 Ab-bound/cell [3863-8934]; median lymphocyte count, 0.9Giga/L [0.6-1.3]; neutrophil-to-lymphocyte ratio, 10.9 [6.5-19.7]. Overall, 146 cases (68.5%) had tracheal colonization with Candida spp. An episode of VAP occurred (either for the first or only time) in 62 (29.1%) cases 5.5 days (median) after D0; a second episode occurred in 12 (5.6%) cases, 15.5 days (median) after D0. After adjustment, bronchial colonization with Candida was not associated with VAP [adjusted cause-specific hazard ratio = 0.98 (0.59-1.65), p = 0.95]. CONCLUSION In patients with mechanical ventilation for more than 4 days and multiple organ failure, bronchial colonization with Candida spp. was not associated with VAP, even after adjustment for immune function.
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Fourie R, Pohl CH. Beyond Antagonism: The Interaction Between Candida Species and Pseudomonas aeruginosa. J Fungi (Basel) 2019; 5:jof5020034. [PMID: 31010211 PMCID: PMC6617365 DOI: 10.3390/jof5020034] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/18/2019] [Accepted: 04/18/2019] [Indexed: 12/11/2022] Open
Abstract
There are many examples of the interaction between prokaryotes and eukaryotes. One such example is the polymicrobial colonization/infection by the various opportunistic pathogenic yeasts belonging to the genus Candida and the ubiquitous bacterium, Pseudomonas aeruginosa. Although this interaction has simplistically been characterized as antagonistic to the yeast, this review highlights the complexity of the interaction with various factors influencing both microbes. The first section deals with the interactions in vitro, looking specifically at the role of cell wall components, quorum sensing molecules, phenazines, fatty acid metabolites and competition for iron in the interaction. The second part of this review places all these interactions in the context of various infection or colonization sites, i.e., lungs, wounds, and the gastrointestinal tract. Here we see that the role of the host, as well as the methodology used to establish co-infection, are important factors, influencing the outcome of the disease. Suggested future perspectives for the study of this interaction include determining the influence of newly identified participants of the QS network of P. aeruginosa, oxylipin production by both species, as well as the genetic and phenotypic plasticity of these microbes, on the interaction and outcome of co-infection.
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Affiliation(s)
- Ruan Fourie
- Department of Microbial, Biochemical and Food Biotechnology, University of the Free State, Bloemfontein 9301, South Africa.
| | - Carolina H Pohl
- Department of Microbial, Biochemical and Food Biotechnology, University of the Free State, Bloemfontein 9301, South Africa.
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Respiratory Tract Colonization by Candida species Portends Worse Outcomes in Immunocompromised Patients. ACTA ACUST UNITED AC 2018; 25:197-201. [PMID: 30911217 DOI: 10.1097/cpm.0000000000000279] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background The significance and clinical management of Candida colonization of the respiratory tract are ill-defined. We now report the frequency of Candida species from the lower respiratory tract in hematopoietic stem cell transplant recipients (HSCT) undergoing bronchoscopy with broncheoalveolar lavage (BAL) for pneumonitis post-HSCT. Methods The University of Michigan Clinical Microbiology Lab Database was queried for all respiratory cultures positive for Candida species between 2000-2012. We concurrently performed a retrospective analysis of 515 HSCT recipients with pneumonitis at our institution between 2001-2012. Results During this twelve-year period, there were 2524 unique Candida isolates (78% Candida albicans). Of the 515 HSCT patients with suspected pneumonitis,127 (24.7%) HSCT subjects were culture positive for a fungal pathogen, with Candida species identified in 27 cases (5.2%). When compared with other HSCT subjects, those cultures positive for Candida had significantly increased mortality (p=0.04). Conclusions Candida sp. are commonly cultured from the respiratory tract of HSCT recipients, with increased mortality in affected patients. While there is insufficient evidence for anti-fungal treatment of Candida species colonization, the presence of the yeast may be useful as a surrogate marker of disease severity.
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Arvanitis M, Mylonakis E. Characteristics, Clinical Relevance, and the Role of Echinocandins in Fungal-Bacterial Interactions. Clin Infect Dis 2016; 61 Suppl 6:S630-4. [PMID: 26567281 DOI: 10.1093/cid/civ816] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Fungal-bacterial interactions are common in the environment. The interactions between invasive fungi (eg, Candida species and Aspergillus species) and pathogenic bacteria can be particularly significant in the outcome of human infections. Study of these interactions in vivo using murine or invertebrate models, such as Caenorhabditis elegans or Galleria mellonella, has been very helpful in increasing our understanding of the pathogenesis of mixed infections and in identifying ways to use this between-kingdom interplay to our advantage. Based on their effect against fungal biofilms and their immunomodulatory properties, the newer class of antifungal agents, known as echinocandins, has the potential to be useful in polymicrobial infections and in high-risk complex infections such as ventilator-associated pneumonia or sepsis where colonization by fungi can lead to worse outcomes.
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Affiliation(s)
- Marios Arvanitis
- Infectious Diseases Division, Rhode Island Hospital Warren Alpert Medical School of Brown University, Providence, Rhode Island Internal Medicine Department, Boston Medical Center, Massachusetts
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Rhode Island Hospital Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Hurley JC. Impact of selective digestive decontamination on respiratory tract Candida among patients with suspected ventilator-associated pneumonia. A meta-analysis. Eur J Clin Microbiol Infect Dis 2016; 35:1121-35. [PMID: 27116009 DOI: 10.1007/s10096-016-2643-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 03/29/2016] [Indexed: 12/18/2022]
Abstract
The purpose here is to establish the incidence of respiratory tract colonization with Candida (RT Candida) among ICU patients receiving mechanical ventilation within studies in the literature. Also of interest is its relationship with candidemia and the relative importance of topical antibiotic (TA) use as within studies of selective digestive decontamination (SDD) versus other candidate risk factors towards it. The incidence of RT Candida was extracted from component (control and intervention) groups decanted from studies of various TA and non-TA ICU infection prevention methods with summary estimates derived using random effects. A benchmark RT Candida incidence to provide overarching calibration was derived using (observational) groups from studies without any prevention method under study. A multi-level regression model of group level data was undertaken using generalized estimating equation (GEE) methods. RT Candida data were sourced from 113 studies. The benchmark RT Candida incidence is 1.3; 0.9-1.8 % (mean and 95 % confidence intervals). Membership of a concurrent control group of a study of SDD (p = 0.02), the group-wide presence of candidemia risk factors (p < 0.001), and proportion of trauma admissions (p = 0.004), but neither the year of study publication, nor membership of any other component group, nor the mode of respiratory sampling are predictive of the RT Candida incidence. RT Candida and candidemia incidences are correlated. RT Candida incidence can serve as a basis for benchmarking. Several relationships have been identified. The increased incidence among concurrent control groups of SDD studies cannot be appreciated in any single study examined in isolation.
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Affiliation(s)
- J C Hurley
- Department of Rural Health, Melbourne Medical School, University of Melbourne, Parkville, Australia. .,Internal Medicine Service Ballarat Health Services, PO Box 577, Ballarat, Australia, 3353. .,Infection Control Committees, St John of God Hospital and Ballarat Health Services, Ballarat, Victoria, Australia.
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15
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Fourie R, Ells R, Swart CW, Sebolai OM, Albertyn J, Pohl CH. Candida albicans and Pseudomonas aeruginosa Interaction, with Focus on the Role of Eicosanoids. Front Physiol 2016; 7:64. [PMID: 26955357 PMCID: PMC4767902 DOI: 10.3389/fphys.2016.00064] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 02/11/2016] [Indexed: 12/20/2022] Open
Abstract
Candida albicans is commonly found in mixed infections with Pseudomonas aeruginosa, especially in the lungs of cystic fibrosis (CF) patients. Both of these opportunistic pathogens are able to form resistant biofilms and frequently infect immunocompromised individuals. The interaction between these two pathogens, which includes physical interaction as well as secreted factors, is mainly antagonistic. In addition, research suggests considerable interaction with their host, especially with immunomodulatory lipid mediators, termed eicosanoids. Candida albicans and Pseudomonas aeruginosa are both able to utilize arachidonic acid (AA), liberated from the host cells during infection, to form eicosanoids. The production of these eicosanoids, such as Prostaglandin E2, by the host and the pathogens may affect the dynamics of polymicrobial infection and the outcome of infections. It is of considerable importance to elucidate the role of host-produced, as well as pathogen-produced eicosanoids in polymicrobial infection. This review will focus on in vitro as well as in vivo interaction between C. albicans and P. aeruginosa, paying special attention to the role of eicosanoids in the cross-talk between host and the pathogens.
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Affiliation(s)
- Ruan Fourie
- Pathogenic Yeast Research Group, Department of Microbial, Biochemical and Food Biotechnology, University of the Free State Bloemfontein, South Africa
| | - Ruan Ells
- Pathogenic Yeast Research Group, Department of Microbial, Biochemical and Food Biotechnology, University of the Free StateBloemfontein, South Africa; National Control Laboratory, University of the Free StateBloemfontein, South Africa
| | - Chantel W Swart
- Pathogenic Yeast Research Group, Department of Microbial, Biochemical and Food Biotechnology, University of the Free State Bloemfontein, South Africa
| | - Olihile M Sebolai
- Pathogenic Yeast Research Group, Department of Microbial, Biochemical and Food Biotechnology, University of the Free State Bloemfontein, South Africa
| | - Jacobus Albertyn
- Pathogenic Yeast Research Group, Department of Microbial, Biochemical and Food Biotechnology, University of the Free State Bloemfontein, South Africa
| | - Carolina H Pohl
- Pathogenic Yeast Research Group, Department of Microbial, Biochemical and Food Biotechnology, University of the Free State Bloemfontein, South Africa
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Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, Reboli AC, Schuster MG, Vazquez JA, Walsh TJ, Zaoutis TE, Sobel JD. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1-50. [PMID: 26679628 PMCID: PMC4725385 DOI: 10.1093/cid/civ933] [Citation(s) in RCA: 1888] [Impact Index Per Article: 236.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/02/2015] [Indexed: 02/06/2023] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
| | - Carol A Kauffman
- Veterans Affairs Ann Arbor Healthcare System and University of Michigan Medical School, Ann Arbor
| | | | | | - Kieren A Marr
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | - Thomas J Walsh
- Weill Cornell Medical Center and Cornell University, New York, New York
| | | | - Jack D Sobel
- Harper University Hospital and Wayne State University, Detroit, Michigan
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Gileles-Hillel A, Shoseyov D, Polacheck I, Korem M, Kerem E, Cohen-Cymberknoh M. Association of chronic Candida albicans respiratory infection with a more severe lung disease in patients with cystic fibrosis. Pediatr Pulmonol 2015; 50:1082-9. [PMID: 26383963 DOI: 10.1002/ppul.23302] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 07/27/2015] [Accepted: 08/22/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite the increase in fungal isolates, the significance of chronic Candida albicans airway colonization in CF is unclear. AIM To investigate the impact of C. albicans airway colonization on CF disease severity. METHODS Longitudinal analysis of clinical data from CF patients followed during 2003-2009 at our CF center. Patients were stratified based on their C. albicans colonization status--chronic, intermittent, and none. RESULTS A total of 4,244 cultures were obtained from 91 patients (mean age 19.7 years, range 5-68). The three colonization groups were similar in age, gender,and body mass index (BMI). Compared to the non-colonized group (n = 27, 30%), the chronic C. albicans colonization group (n = 34, 37%), had a significantly lower FEV1 percent predicted (74.3 ± 23.1% vs. 93.9% ± 22.2) with a higher annual rate of FEV1 decline (-1.9 ± 4.2% vs. 0.7 ± 4.5%). The patients who were intermittently colonized with C. albicans had intermediate values. CONCLUSIONS Chronic respiratory colonization of C. albicans is associated with worsening of FEV1 in CF. Prospective studies are needed to confirm this finding and to corroborate whether indeed C. albicans drives a deleterious lung phenotype.
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Affiliation(s)
- Alex Gileles-Hillel
- Department of Pediatrics, Hadassah Hebrew-University Medical Center, Jerusalem, Israel
| | - David Shoseyov
- Department of Pediatrics, Hadassah Hebrew-University Medical Center, Jerusalem, Israel.,Pediatric Pulmonology Unit, Hadassah Hebrew-University Medical Center, Jerusalem, Israel.,Cystic Fibrosis Center, Hadassah Hebrew-University Medical Center, Jerusalem, Israel
| | - Itzhack Polacheck
- Department of Clinical Microbiology and Infectious Diseases, Hadassah Hebrew-University Medical Center, Jerusalem, Israel
| | - Maya Korem
- Department of Clinical Microbiology and Infectious Diseases, Hadassah Hebrew-University Medical Center, Jerusalem, Israel
| | - Eitan Kerem
- Department of Pediatrics, Hadassah Hebrew-University Medical Center, Jerusalem, Israel.,Pediatric Pulmonology Unit, Hadassah Hebrew-University Medical Center, Jerusalem, Israel.,Cystic Fibrosis Center, Hadassah Hebrew-University Medical Center, Jerusalem, Israel
| | - Malena Cohen-Cymberknoh
- Department of Pediatrics, Hadassah Hebrew-University Medical Center, Jerusalem, Israel.,Pediatric Pulmonology Unit, Hadassah Hebrew-University Medical Center, Jerusalem, Israel.,Cystic Fibrosis Center, Hadassah Hebrew-University Medical Center, Jerusalem, Israel
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18
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Reischies FMJ, Prattes J, Prüller F, Eigl S, List A, Wölfler A, Buzina W, Zollner-Schwetz I, Valentin T, Rabensteiner J, Flick H, Krause R, Raggam RB, Hoenigl M. Prognostic potential of 1,3-beta-d-glucan levels in bronchoalveolar lavage fluid samples. J Infect 2015; 72:29-35. [PMID: 26416472 DOI: 10.1016/j.jinf.2015.09.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/20/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The objective of this study was to investigate the prognostic potential of 1,3-beta-d-glucan (BDG) testing in bronchoalveolar lavage fluid (BALF) samples. METHODS A total of 300 BALF samples from 252 patients were investigated for BDG (Fungitell(®) assay). Prognostic potential of BALF BDG was evaluated by using: i.) Kaplan-Meier analysis, and ii.) multivariable Cox hazard regression analyses. RESULTS BALF BDG levels were found to be significantly higher in samples with Candida spp. colonization (p < 0.001). A total of 61/252 patients (24.2%) died within 90-days of BALF sampling (18.1% of patients with BALF BDG <200 pg/mL, 32.4% with BALF BDG ≥200 pg/mL). Kaplan-Meier analysis revealed that overall cumulative 90-day mortality was significantly higher in those with BALF BDG levels ≥200 pg/mL when compared to those with levels <200 pg/mL (log-rank p = 0.006, Breslow p = 0.005 and Tarone-Ware p = 0.005). The multivariable Cox regression analysis showed that BALF BDG levels were a strong predictor of 90-day overall mortality, with a hazard ratio of 1.048 (per 100 pg/mL increase of BALF BDG). CONCLUSION False positive BALF BDG results in the presence of Candida spp. colonization of the lower respiratory tract may explain the limited diagnostic potential of BALF BDG testing. In contrast, prognostic potential of BALF BDG may be promising.
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Affiliation(s)
- Frederike M J Reischies
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Juergen Prattes
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Susanne Eigl
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Agnes List
- Division of Hematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Albert Wölfler
- Division of Hematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Walter Buzina
- Institute of Hygiene, Microbiology and Environmental Medicine, Medical University of Graz, Graz, Austria
| | - Ines Zollner-Schwetz
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Valentin
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jasmin Rabensteiner
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Holger Flick
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Robert Krause
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Reinhard B Raggam
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria.
| | - Martin Hoenigl
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria; Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria; Division of Infectious Diseases, Department of Medicine, University of California, San Diego, USA.
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Terraneo S, Ferrer M, Martín-Loeches I, Esperatti M, Di Pasquale M, Giunta V, Rinaudo M, de Rosa F, Li Bassi G, Centanni S, Torres A. Impact of Candida spp. isolation in the respiratory tract in patients with intensive care unit-acquired pneumonia. Clin Microbiol Infect 2015; 22:94.e1-94.e8. [PMID: 26369603 DOI: 10.1016/j.cmi.2015.09.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/31/2015] [Accepted: 09/02/2015] [Indexed: 10/23/2022]
Abstract
In immunocompetent patients with nosocomial pneumonia, the relationship between Candida spp. isolation in respiratory samples and outcomes or association with other pathogens is controversial. We therefore compared the characteristics and outcomes of patients with intensive care unit-acquired pneumonia (ICUAP), with or without Candida spp. isolation in the respiratory tract. In this prospective non-interventional study, we assessed 385 consecutive immunocompetent patients with ICUAP, according to the presence or absence of Candida spp. in lower respiratory tract samples. Candida spp. was isolated in at least one sample in 82 (21%) patients. Patients with Candida spp. had higher severity scores and organ dysfunction at admission and at onset of pneumonia. In multivariate analysis, previous surgery, diabetes mellitus and higher Simplified Acute Physiology Score II at ICU admission independently predicted isolation of Candida spp. There were no significant differences in the rate of specific aetiological pathogens, the systemic inflammatory response, and length of stay between patients with and without Candida spp. Mortality was also similar, even adjusted for potential confounders in propensity-adjusted multivariate analyses (adjusted hazard ratio 1.08, 95% CI 0.57-2.05, p 0.80 for 28-day mortality and adjusted hazard ratio 1.38, 95% CI 0.81-2.35, p 0.24 for 90-day mortality). Antifungal therapy was more frequently prescribed in patients with Candida spp. in respiratory samples but did not influence outcomes. Candida spp. airway isolation in patients with ICUAP is associated with more initial disease severity but does not influence outcomes in these patients, regardless of the use or not of antifungal therapy.
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Affiliation(s)
- S Terraneo
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Respiratory Unit, San Paolo Hospital, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - M Ferrer
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Ireland.
| | - I Martín-Loeches
- St. James's Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland
| | - M Esperatti
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - M Di Pasquale
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda Milano, Italy
| | - V Giunta
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - M Rinaudo
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - F de Rosa
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda Milano, Italy
| | - G Li Bassi
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Ireland
| | - S Centanni
- Respiratory Unit, San Paolo Hospital, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - A Torres
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Ireland
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Albert M, Heyland D. Candida in the respiratory tract secretions of critically ill patients and the impact of antifungal treatment: reply to Roux and Ricard. Intensive Care Med 2014; 40:1613. [PMID: 25236544 DOI: 10.1007/s00134-014-3492-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Martin Albert
- Centre de recherche de l'Hôpital du Sacré-Coeur de Montréal, Département de Médecine, Université de Montréal, 5400 Gouin Ouest, Montréal, Canada,
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Candida colonization of respiratory tract: to treat or not to treat, will we ever get an answer? Intensive Care Med 2014; 40:1381-4. [DOI: 10.1007/s00134-014-3364-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 06/05/2014] [Indexed: 10/25/2022]
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Albert M, Williamson D, Muscedere J, Lauzier F, Rotstein C, Kanji S, Jiang X, Hall M, Heyland D. Candida in the respiratory tract secretions of critically ill patients and the impact of antifungal treatment: a randomized placebo controlled pilot trial (CANTREAT study). Intensive Care Med 2014; 40:1313-22. [PMID: 24981955 DOI: 10.1007/s00134-014-3352-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 05/22/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE Candida spp. are frequently recovered from endotracheal secretions in critically ill patients suspected of having ventilator-associated pneumonia. Observational studies reported an association with worse clinical outcomes but the effect of antifungal therapy in these patients remains unclear. We designed this pilot study to assess the feasibility of a larger trial and to evaluate inflammatory profiles and clinical outcomes in these patients. METHODS We conducted a double-blind, placebo-controlled, multicenter pilot randomized trial of antifungal therapy in critically ill patients with a clinical suspicion of ventilator-associated pneumonia with positive airway secretion specimens for Candida spp. We also included an observational group without Candida spp. in their airway secretions. We measured recruitment rate, inflammatory and innate immune function profiles over time, and clinical outcomes. RESULTS We recruited 60 patients into the randomized trial and 29 patients into the observational study. Markers of inflammation and all clinical outcomes were comparable between placebo and antifungal treatment group at baseline and over time. At baseline, plasma TNF-α levels were higher in patients with VAP and Candida compared to the observational group (mean ± SD) (21.8 ± 23.1 versus 12.4 ± 9.3 pg/ml, p = 0.02) and these patients had lower innate immune function as evidenced by reduced whole blood ex vivo LPS-induced TNF-α production capacity (854.8 ± 855.2 versus 1,559.4 ± 1,290.6 pg/ml, p = 0.01). CONCLUSIONS This study does not provide evidence to support a larger trial examining the efficacy of empiric antifungal treatment in patients with a clinical suspicion of ventilator-associated pneumonia and Candida in the endotracheal secretions. The presence of Candida in the lung may be associated with persistent inflammation and immunosuppression.
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Affiliation(s)
- Martin Albert
- Département de Médecine, Centre de recherche de l'Hôpital du Sacré-Coeur de Montréal, Université de Montréal, 5400 Gouin Ouest, Montreal, Canada,
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Arvanitis M, Anagnostou T, Kourkoumpetis TK, Ziakas PD, Desalermos A, Mylonakis E. The impact of antimicrobial resistance and aging in VAP outcomes: experience from a large tertiary care center. PLoS One 2014; 9:e89984. [PMID: 24587166 PMCID: PMC3937398 DOI: 10.1371/journal.pone.0089984] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 01/23/2014] [Indexed: 02/07/2023] Open
Abstract
Background Ventilator associated pneumonia (VAP) is a serious infection among patients in the intensive care unit (ICU). Methods We reviewed the medical charts of all patients admitted to the adult intensive care units of the Massachusetts General Hospital that went on to develop VAP during a five year period. Results 200 patients were included in the study of which 50 (25%) were infected with a multidrug resistant pathogen. Increased age, dialysis and late onset (≥5 days from admission) VAP were associated with increased incidence of resistance. Multidrug resistant bacteria (MDRB) isolation was associated with a significant increase in median length of ICU stay (19 vs. 16 days, p = 0.02) and prolonged duration of mechanical ventilation (18 vs. 14 days, p = 0.03), but did not impact overall mortality (HR 1.12, 95% CI 0.51–2.46, p = 0.77). However, age (HR 1.04 95% CI 1.01–1.07, p = 0.003) was an independent risk factor for mortality and age ≥65 years was associated with increased incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections (OR 2.83, 95% CI 1.27–6.32, p = 0.01). Conclusions MDRB-related VAP is associated with prolonged ICU stay and mechanical ventilation. Interestingly, age ≥ 65 years is associated with MRSA VAP.
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Affiliation(s)
- Marios Arvanitis
- Department of Medicine, Infectious Diseases Division, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
- Department of Medicine, Infectious Disease Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Theodora Anagnostou
- Department of Medicine, Infectious Diseases Division, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
- Department of Medicine, Infectious Disease Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Themistoklis K. Kourkoumpetis
- Department of Medicine, Infectious Disease Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Panayiotis D. Ziakas
- Department of Medicine, Infectious Diseases Division, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Athanasios Desalermos
- Department of Medicine, Infectious Disease Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Eleftherios Mylonakis
- Department of Medicine, Infectious Diseases Division, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
- Department of Medicine, Infectious Disease Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Muscedere J, Ofner M, Kumar A, Long J, Lamontagne F, Cook D, McGeer A, Chant C, Marshall J, Jouvet P, Fowler R. The occurrence and impact of bacterial organisms complicating critical care illness associated with 2009 influenza A(H1N1) infection. Chest 2013; 144:39-47. [PMID: 23392627 DOI: 10.1378/chest.12-1861] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Although secondary infections are recognized as a cause of morbidity and mortality in seasonal influenza, their frequency, characteristics, and associated clinical outcomes in 2009 influenza A(H1N1) (A[H1N1])-related critical illness are unknown. METHODS In a prospective cohort of adult patients admitted to Canadian ICUs with influenza A(H1N1) infection, the frequency and associated clinical outcomes of prevalent (culture taken within 72 h of ICU admission) and ICU-acquired (culture taken after 72 h from ICU admission) positive bacterial cultures were determined. RESULTS Among 681 patients, the mean age was 47.9 years (SD, 15.1), APACHE (Acute Physiology and Chronic Health Examination) II score was 21.0 (9.9), and 573 patients (84.0%) were invasively mechanically ventilated. Positive cultures were obtained in 259 patients (38.0%): 77 (29.7%) had prevalent, 115 (44.4%) had ICU-acquired, and 40 (15.4%) had both; culture date was unavailable in 27 (10.4%). The most common bacterial organisms isolated were coagulase-negative staphylococci, Staphylococcus aureus, Pseudomonas species, and Streptococcus pneumoniae. Antibiotics were prescribed in 661 (97.1%), with 3.8 (1.9) prescriptions per patient. Patients with any positive culture had longer days of mechanical ventilation (mean [SD], 15.2 [10.7] vs 10.7 [9.0]; P<.0001), ICU stay (median [interquartile range (IQR)], 18.2 [12.5] days vs 10.8 [9.0] days, P<.0001), and hospitalization (median [IQR], 30.7 [20.7] days vs 19.2 [17.4] days, P<.0001) and a trend toward increased hospital mortality (25.1% vs 19.9%, P=.15). Patients with ICU-acquired positive cultures had worse outcomes compared with those with positive prevalent cultures or who were culture-negative. CONCLUSION Culture-based evidence of secondary infections commonly complicates A(H1N1)-related critical illness and is associated with worse clinical outcomes despite nearly ubiquitous antibiotic administration.
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Affiliation(s)
- John Muscedere
- Department of Medicine, Queen's University, Kingston, ON.
| | - Marianna Ofner
- Public Health Agency of Canada, Ottawa, ON and Winnipeg, MB
| | - Anand Kumar
- Winnipeg Health Sciences Centre and St. Boniface Hospital, University of Manitoba, Winnipeg, MB
| | - Jennifer Long
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON
| | - Francois Lamontagne
- Clinical Research Centre Étienne Le Bel and Department of Medicine, Université de Sherbrooke, Sherbrooke, QC
| | - Deborah Cook
- Faculty of Health Sciences, McMaster University, Hamilton, ON
| | | | | | | | - Philippe Jouvet
- Sainte-Justine Research Center, Université de Montréal, QC, Canada
| | - Robert Fowler
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON
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Candida colonization in ventilated ICU patients: no longer a bystander! Intensive Care Med 2012; 38:1243-5. [DOI: 10.1007/s00134-012-2587-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 04/12/2012] [Indexed: 12/21/2022]
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Hamet M, Pavon A, Dalle F, Pechinot A, Prin S, Quenot JP, Charles PE. Candida spp. airway colonization could promote antibiotic-resistant bacteria selection in patients with suspected ventilator-associated pneumonia. Intensive Care Med 2012; 38:1272-9. [DOI: 10.1007/s00134-012-2584-2] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 03/07/2012] [Indexed: 12/01/2022]
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Harriott MM, Noverr MC. Importance of Candida-bacterial polymicrobial biofilms in disease. Trends Microbiol 2011; 19:557-63. [PMID: 21855346 DOI: 10.1016/j.tim.2011.07.004] [Citation(s) in RCA: 219] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 06/30/2011] [Accepted: 07/21/2011] [Indexed: 12/15/2022]
Abstract
Candida albicans is the most prevalent human fungal pathogen, with an ability to inhabit diverse host niches and cause disease in both immunocompetent and immunocompromised individuals. C. albicans also readily forms biofilms on indwelling medical devices and mucosal tissues, which serve as an infectious reservoir that is difficult to eradicate, and can lead to lethal systemic infections. Biofilm formation occurs within a complex milieu of host factors and other members of the human microbiota. Polymicrobial interactions will probably dictate the cellular and biochemical composition of the biofilm, as well as influence clinically relevant outcomes, such as drug and host resistance and virulence. In this manuscript, we review C. albicans infections in the context of in vivo polymicrobial biofilms and implications for pathogenesis.
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Affiliation(s)
- Melphine M Harriott
- Department of Medicine, Division of Infectious Diseases, Henry Ford Hospital, Detroit, MI 48202, USA
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Heo SM, Sung RS, Scannapieco FA, Haase EM. Genetic relationships between Candida albicans strains isolated from dental plaque, trachea, and bronchoalveolar lavage fluid from mechanically ventilated intensive care unit patients. J Oral Microbiol 2011; 3:JOM-3-6362. [PMID: 21731911 PMCID: PMC3124833 DOI: 10.3402/jom.v3i0.6362] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 05/19/2011] [Accepted: 05/20/2011] [Indexed: 11/14/2022] Open
Abstract
Candida albicans often resides in the oral cavity of healthy humans as a harmless commensal organism. This opportunistic fungus can cause significant disease in critically ill patients, such as those undergoing mechanical ventilation in the intensive care unit (ICU) having compromised local airway defense mechanisms. The goal of this study was to determine the intra- and inter-patient genetic relationship between strains of C. albicans recovered from dental plaque, tracheal secretions, and the lower airway by bronchoalveolar lavage of patients undergoing mechanical ventilation. Three pulsed-field gel electrophoresis (PFGE) typing methods were used to determine the genetic relatedness of the C. albicans strains, including electrophoretic karyotyping (EK) and restriction endonuclease analysis of the genome using SfiI (REAG-S) and BssHII (REAG-B). The C. albicans isolates from dental plaque and tracheo-bronchial sites from the same patient were genetically indistinguishable and retained over time, whereas strains from different patients usually separated into different genotypes. Among the three methods, REAG-B proved to be the most discriminatory method to differentiate isolates. The finding of genetically similar strains from the oral and tracheo-bronchial sites from the same patient supports the notion that the oral cavity may serve as an important source for C. albicans spread to the trachea and lung of mechanically ventilated patients.
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Affiliation(s)
- Seok-Mo Heo
- Department of Oral Biology, University at Buffalo, The State University of New York, Buffalo, NY, USA
- Periodontics and Endodontics, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Robert S. Sung
- Department of Oral Biology, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Frank A. Scannapieco
- Department of Oral Biology, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Elaine M. Haase
- Department of Oral Biology, University at Buffalo, The State University of New York, Buffalo, NY, USA
- Elaine M. Haase, University at Buffalo, Department of Oral Biology, 109 Foster Hall, 3435 Main Street, Buffalo, NY 14214. Tel: 716-829-2520. Fax: 716-829-3942.
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